1. Field of the Invention
The present invention relates, in general, to systems and method for discouraging fraud, and, more particularly, to software, systems and methods for discouraging and preventing healthcare fraud.
2. Relevant Background
In the United States, for example, more than 4 billion health insurance benefit transactions are processed every year. These benefit transactions are handled by private health insurance plans as well as tax-funded insurance programs such as Medicare and Medicaid. Healthcare fraud is the deliberate submittal of false claims for reimbursement to these private health payers and public programs. In either case, society at large ultimately suffers from these loses of healthcare fraud through higher health insurance premiums, restricted benefits, higher taxes and higher insurance co-payments for privately and publicly insured patients.
Even though only a small percentage of these transactions are fraudulent, the total value of the losses caused by this fraud is staggering. The National Health Care Anti-Fraud Association reports that health care fraud resulted in theft of $1.3 trillion in calendar-year 2000 alone. On Feb. 21, 2002, the United States Department of Health and Human Services reported its finding that of the $191.8 billion in claims paid in 2001, 6.3 percent—amounting to $12.1 billion—should not have been paid due to erroneous billing or payment, inadequate provider documentation of services to back up the claims and/or outright fraud.
One of the largest single sources of health care fraud is dishonest health care providers (e.g., physicians, chiropractors, osteopaths, and alternative-medicine care givers). Although the vast majority of health care providers are honest, the dishonest minority are uniquely situated to conduct systemic, ongoing and broad scale fraud that has been, until now, difficult to detect and prove. For example, health care providers have access to patient identities and insurance/Medicare/Medicaid information of those patients, knowledge of the reimbursement processes, access to the provider reimbursement systems, and a familiarity with fraudulent claims that are difficult to detect.
A common fraud involves billing for services that were never rendered. This may involve using genuine patient information to fabricate entire claims or may involve padding claims with charges for procedures or services that did not take place. In a common scenario, a health care provider gains authority to perform a series of treatments over a period of time, then performs only some of the treatments while submitting reimbursement for the entire series. While current regulations require a patient signature indicating that services were performed, a dishonest provider often convinces the patient to sign these verification forms in advance. The patient may or may not be aware of the fraud. Currently, unless the patient discovers and informs the insurance company or government program that they did not receive the services, the fraud is difficult to detect.
The existence of dishonest providers harms the vast majority of honest providers in that all providers are subject to increased scrutiny, more complex forms, and allegations of fraud stemming from innocent mistakes in handling claims. As a result, fraud creates a chilling effect on all honest care providers that desire to give their patients the best care possible. This chilling effect impacts courts, regulatory agencies, and the legal system as well as the existence of fraud creates a cloud of doubt around all people who submit or prosecute claims for health care reimbursement on behalf of victims of accidents, on-the-job injuries, and other legitimate reimbursable claims.
The current response to healthcare fraud involves creating criminal and civil penalties for abuse. While such steps are necessary, they have limited effect unless the fraud can be discovered and proven. Discovery is difficult and insurance companies and government agencies are expending greater and greater resources in anti-fraud processes. More recently, “whistleblower” programs are being used to encourage fraud reporting by patients themselves. However, because patients implicitly trust their healthcare providers and often lack the sophisticated knowledge to detect fraud, these programs have limited effect.
Technological solutions have been proposed that involve collecting data about healthcare transaction and using data mining and sophisticated matching techniques to identify some types of fraud. While such systems can be useful in detecting some fraud such as double billing, over prescription, and the like, they are not generally useful to detect all fraud relating to submission of claims for services that have not been provided. These solutions rely on databases that hold detailed information about patients and medical histories of those patients. New regulations under the health insurance portability and privacy act make it more difficult or impossible to collect and use such information.
Accordingly, a need exists for systems, methods, and software that discourage and prevent healthcare fraud.